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Case presentation
Intestinal obstruction
intern
deepak paudel
GMCTH
DEPARTMENT OF SURGERY
68yr/M from Armala ,Ex Army by profession was admitted
through GMC ER on 27th of Asad 2073( @ 10:20 PM) with chief
complai...
HOPI
• Pain - in RIF
gradual on onset
burning sensation
continuous
started in the morning
non radiating
no known aggravati...
Pain is associated with
abdominal distention
water brash
nausea
burning micturation
H/O loss of appetite
• H/O passage of hard stool
• No H/O fever ,headache ,trauma
• No H/0 cough ,weight loss
• No H/0 vomiting.
PAST HISTORY
• H/0 appendectomy 40 yrs ago
• From than ,he started to develop abdominal
pain of similar nature .
• Accordi...
FAMILY HISTORY
• No such H/O in the family
• no H/O of HTN, DM, TB
PERSONAL HISTORY
• Consumes alcohol occasionally.
• Non vegeterian
• Doesn’t smoke
• But has a habit of chewing tobacco.
ALLERGIC HISTORY
• No known allergic history of any drug
• GENERAL EXAMINATION
Pt .was concious, well oriented to T,P,P lying comfortably in supine
position with cannula fitted in...
• Pallor
• Icterus
• Lymphadenopathy nil
• Clubbing
• Cyanosis
• Oedema nil
• Dehydration
GI EXAMINATION
Inspection
-umbilicus centrally placed and abdomen is
distended.
-visible scar in rt iliac fossa
-all quadr...
Palpation
-Abdominal girth :90 cm(01) -86 cm(02) -72 cm (04/04)
-local temprature normal
-tenderness on lower abdominal re...
Percussion – resonant note
- tender RIF
-shifting dullness –ve
auscultation – normal bowel sound heard
-no vascular bruits...
• Respiratory exmn-normal
• CVS exmn- normal
• CNS exmn –normal
Provisional diagnosis
• Intestinal obstruction:
For abdominal pain
Constipation
Abdominal distention
Differential Diagnosis
D/d For Against
Meckels
Diverticulitis
Pain abdomen No antecedent
h/o of lower GI
bleeding
Rt. Uret...
D/D For Against
Perforated peptic
ulcer
Severe pain in
RIF
history of
dyspepsia
pain is not
related to food
intake.
Crohns...
Investigation
• CBC:-WBC -10,000/mm3
• Na+ 141 ,k+ 4.0
• USG impression :
slightly prominent bowel loop.
• Plain abdominal...
Treatment
• Under liquid diet.
• IV fluids
• Analgesics:inj tramadol ,buscopan,
• Antibiotics :levoflox,inj xone
• Soap wa...
Intestinal obstruction
Definition:
• Intestinal Obstruction(IO) is a condition in
which there is a sudden stoppage of the
onward passage of intes...
Intestine
CLASSIFICATION
According to:
Aetiopathology
Onset
Level
Nature
Peristalsis is working against
a mechanical obstruction
DYNAMIC
(MECHANICAL)
Result from atony of the
intestine with loss ...
Small or Large bowel
High (Proximal) or Low (Distal) small bowel
According to LEVEL
High IO- near the ampulla- jejunum and
proximal ileum.
Low IO- distal to the ampulla- distal ileum
and colon.
According to nature of Obstruction:
1. Simple Obstruction- the bowel lumen is occluded ,blood supply remains
intact. The s...
3. Closed loop obstruction- The bowel is
obstructed both proximally and distally. Here
the blood supply may be impaired.
A...
Closed loop obstruction
According to onset:
-Chronic Obstruction-Usually seen in large
bowel obstruction. The symptoms may arise
from the cause an...
Causes Dynamic obstructrion
BANDS
Ball of Ascaris worms
Adynamic cause of Obstruction
• Paralytic ileus
• Electrolyte imbalance
• Spinal injury
• Diabetis mellitus
• Renal surger...
Pathophysiology
Clinical presentation
The clinical presentation varies according to;
- The location of the obstruction
- The age of the ob...
Clinical features
• Abdominal pain
• Vomiting
• Distension
• Constipation
• Dehydration
• Feature of toxemia and septicemi...
Small vs large bowel obstruction
Investigation
• CBC
• Electrolyte Na/K
• Plan X-ray abdomen erect and supine
• CT scan
A. Investigations
(i) Supportive- FBC, BU+Cr. Other investigations may be
requested on the basis of clinical suspicion.
(i...
Managmenet
I.V fluids and electrolytes rescusitation
N.G tube if repeated vomiting
Antibiotics
Exploratory laparatomy
Hern...
• SRB’s Manual of surgery, 4E
• Bailey & Love’s Short practice of surgery, 25th
Edition
• Principles of surgery
• Internet...
Intestinal obstruction
Intestinal obstruction
Intestinal obstruction
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Intestinal obstruction

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case presentation on intestional obstruction

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Intestinal obstruction

  1. 1. Case presentation Intestinal obstruction intern deepak paudel GMCTH DEPARTMENT OF SURGERY
  2. 2. 68yr/M from Armala ,Ex Army by profession was admitted through GMC ER on 27th of Asad 2073( @ 10:20 PM) with chief complaints of: • pain abdomen for 3 days • Dyspepsia for 3 days • Abdominal distention for 3 days
  3. 3. HOPI • Pain - in RIF gradual on onset burning sensation continuous started in the morning non radiating no known aggravating factor relieved by shifting position
  4. 4. Pain is associated with abdominal distention water brash nausea burning micturation H/O loss of appetite
  5. 5. • H/O passage of hard stool • No H/O fever ,headache ,trauma • No H/0 cough ,weight loss • No H/0 vomiting.
  6. 6. PAST HISTORY • H/0 appendectomy 40 yrs ago • From than ,he started to develop abdominal pain of similar nature . • According to him, he experiences similar problem once in every year. • Last time on Bhadra 2072 he was admitted to GMCTH for abdominal pain ,admitted ,treated conservatively and relieved.
  7. 7. FAMILY HISTORY • No such H/O in the family • no H/O of HTN, DM, TB
  8. 8. PERSONAL HISTORY • Consumes alcohol occasionally. • Non vegeterian • Doesn’t smoke • But has a habit of chewing tobacco.
  9. 9. ALLERGIC HISTORY • No known allergic history of any drug
  10. 10. • GENERAL EXAMINATION Pt .was concious, well oriented to T,P,P lying comfortably in supine position with cannula fitted in the left hand - Vitals R/R:-25/min BP:- 110/70 mm of Hg in rt brachial Artery. Pulse-84beats/min Temp 98 F
  11. 11. • Pallor • Icterus • Lymphadenopathy nil • Clubbing • Cyanosis • Oedema nil • Dehydration
  12. 12. GI EXAMINATION Inspection -umbilicus centrally placed and abdomen is distended. -visible scar in rt iliac fossa -all quadrants move equally with respiration -no visible pulsation and peristalsis -hernial sites intact -ext. genitilia-normal
  13. 13. Palpation -Abdominal girth :90 cm(01) -86 cm(02) -72 cm (04/04) -local temprature normal -tenderness on lower abdominal region -no palpable mass -no organomegaly -hernial sites intact and normal ext. genital
  14. 14. Percussion – resonant note - tender RIF -shifting dullness –ve auscultation – normal bowel sound heard -no vascular bruits heard P/R exm- no mass, no blood, faeces present.
  15. 15. • Respiratory exmn-normal • CVS exmn- normal • CNS exmn –normal
  16. 16. Provisional diagnosis • Intestinal obstruction: For abdominal pain Constipation Abdominal distention
  17. 17. Differential Diagnosis D/d For Against Meckels Diverticulitis Pain abdomen No antecedent h/o of lower GI bleeding Rt. Ureteric colic Abdominal Pain Aggravated on movement No history of hematuria no radiation to loin
  18. 18. D/D For Against Perforated peptic ulcer Severe pain in RIF history of dyspepsia pain is not related to food intake. Crohns diseases Pain abdomen No diarrhoea and wt loss
  19. 19. Investigation • CBC:-WBC -10,000/mm3 • Na+ 141 ,k+ 4.0 • USG impression : slightly prominent bowel loop. • Plain abdominal X-ray
  20. 20. Treatment • Under liquid diet. • IV fluids • Analgesics:inj tramadol ,buscopan, • Antibiotics :levoflox,inj xone • Soap water enema.
  21. 21. Intestinal obstruction
  22. 22. Definition: • Intestinal Obstruction(IO) is a condition in which there is a sudden stoppage of the onward passage of intestinal contents-i.e. Gas, digestive juices and food
  23. 23. Intestine
  24. 24. CLASSIFICATION According to: Aetiopathology Onset Level Nature
  25. 25. Peristalsis is working against a mechanical obstruction DYNAMIC (MECHANICAL) Result from atony of the intestine with loss of normal peristalsis, in the absence of a mechanical cause. or it may be present in a non- propulsive form (e.g. mesenteric vascular occlusion or pseudo- obstruction) ADYNAMIC (FUNCTIONAL)
  26. 26. Small or Large bowel High (Proximal) or Low (Distal) small bowel According to LEVEL
  27. 27. High IO- near the ampulla- jejunum and proximal ileum. Low IO- distal to the ampulla- distal ileum and colon.
  28. 28. According to nature of Obstruction: 1. Simple Obstruction- the bowel lumen is occluded ,blood supply remains intact. The source of obstruction is usually intra-abdominal. ( Eg. Intra- abdominal adhesions, very rarely gallstones, ball of worms, bezoars). 2. Strangulation- the bowel lumen together with its blood supply is cut-off. Eg. Strangulated inguinal hernias. Pure strangulation without bowel luminal narrowing is usually due to mesenteric embolism/thrombosis.
  29. 29. 3. Closed loop obstruction- The bowel is obstructed both proximally and distally. Here the blood supply may be impaired. A classic example is seen in an obstruction of the colon with a competent ileo-caecal valve. NB: All the 3 types spoken about can occur at the same time for example in a strangulated inguinal hernia.
  30. 30. Closed loop obstruction
  31. 31. According to onset: -Chronic Obstruction-Usually seen in large bowel obstruction. The symptoms may arise from the cause and the subsequent obstruction. -Acute on Chronic Obstruction- sudden obstruction in a previously incomplete obstruction. Sub-acute Obstruction- There is a partial obstruction.
  32. 32. Causes Dynamic obstructrion
  33. 33. BANDS
  34. 34. Ball of Ascaris worms
  35. 35. Adynamic cause of Obstruction • Paralytic ileus • Electrolyte imbalance • Spinal injury • Diabetis mellitus • Renal surgeries • Mesenteric ischemia
  36. 36. Pathophysiology
  37. 37. Clinical presentation The clinical presentation varies according to; - The location of the obstruction - The age of the obstruction - Underlying pathology - Presence or absence of intestinal ischaemia.
  38. 38. Clinical features • Abdominal pain • Vomiting • Distension • Constipation • Dehydration • Feature of toxemia and septicemia • Feature of strangulation • Temperature • Bowel sound • Per rectal examination
  39. 39. Small vs large bowel obstruction
  40. 40. Investigation • CBC • Electrolyte Na/K • Plan X-ray abdomen erect and supine • CT scan
  41. 41. A. Investigations (i) Supportive- FBC, BU+Cr. Other investigations may be requested on the basis of clinical suspicion. (ii)Diagnostic -Plain abdominal x-rays Erect and supine -CXR -Enema -Endoscopic techniques
  42. 42. Managmenet I.V fluids and electrolytes rescusitation N.G tube if repeated vomiting Antibiotics Exploratory laparatomy Hernia  operation Adhesions  Adhesiolysis Obstruction  remove Volvulus  derotate and or operate Mesenteric ischemia  operate Abscess or peritonitis  drain and treat Intussusception  pneumatic or barium reduction or operate
  43. 43. • SRB’s Manual of surgery, 4E • Bailey & Love’s Short practice of surgery, 25th Edition • Principles of surgery • Internet REFRENCES:

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